A patient with a syrinx around the C4 level presents for shunting to drain the syrinx. A small incision in the pia was made and the shunt tube was threaded into the cyst cavity. Clear cystic fluid came forth and the cord was seen to collapse. What is the appropriate ICD-10-PCS code assignment for the shunting of the syrinx?
In this case, the objective of the surgery is to remove the abnormal fluid collection from circulation, so it can be excreted from the body. The syrinx is being drained internally, rather than to the outside. The root operation “Drainage” is more appropriate than “Bypass,” since “Bypass” involves altering the route of passage of the fluid so it can continue to be used by the body. Assign the following ICD-10-PCS procedure code:
009W00Z Drainage of cervical spinal cord with drainage device, open approach
The operative report states that an incision was made in the pia mater to reach the cyst cavity. The pia mater is the innermost layer of the spinal meninges, therefore the site of the procedure is beyond the spinal meninges, in the spinal cord itself. Syrinx refers to a pathological tube-shaped cavity in the brain or spinal cord. In this instance, it was located around the C4 level and therefore “cervical spinal cord” was assigned as the body part.